<%= form_for(resource, :as => resource_name, :url => registration_path(resource_name), :html => { :method => :put }) do |f| %>
<div id="login">
  <div id="cap-top"></div>
  <div id="cap-body">
    <div id="branding">
      <%= image_tag "pophealth_welcome.png", :id => 'imgLogo', :alt => 'popHealth logo' %>
    </div>
    <div class="panel">
      <div class="accountError">
        <%= devise_error_messages! %>
      </div>
      <h1>Update your popHealth account information</h1>
      <ul class="register">
        <li>
            <label for="first_name">Your First Name:</label>
            <%= f.text_field :first_name %>
        </li>
        <li>
            <label for="last_name">Your Last Name:</label>
            <%= f.text_field :last_name %>
        </li>
        <li>
            <label for="username">popHealth User Name:</label>
            <%= f.text_field :username %>
            <p>Must be at least 5 characters long.</p>
        </li>
        <li>
          <label for="email">Your Email Address:</label>
          <%= f.text_field :email %>
        </li>
        <li>
            <label for="company">Your Organization:</label>
            <%= f.text_field :company %>
        </li>
        <li>
            <label for="company_url">Your Organization URL:</label>
            <%= f.text_field :company_url %>
        </li>
        <li>
            <label for="registry_name">Registry Name:</label>
            <%= f.text_field :registry_name %>
        </li>
        <li>
          <label for="registry_id">Registry Identifier:</label>
          <%= f.text_field :registry_id %>
        </li>
        <li>
            <label for="npi">National Provider Id:</label>
            <%= f.text_field :npi %>
        </li>
        <li>
          <label for="tin">Tax Identifier:</label>
          <%= f.text_field :tin %>
        </li>
      </ul>

      <div class="actions">
          <a class="whitebutton" href="/"><span>Cancel</span></a>
          <a class="bluebutton" href='#' onclick="submitRegisterform();"><span>Update Account</span></a>
      </div>
    </div><!-- end div.panel -->
    </div><!-- end #cap-body -->
  <div id="cap-bottom"></div>
</div><!-- END #login -->
<% end %>
